1. A patient arrives at the emergency department complaining of mid-sternal chest pain.

Which of the following nursing action should take priority? A. A complete history with emphasis on preceding events. B. An electrocardiogram. C. Careful assessment of vital signs. D. Chest e am with auscultation.

!. A patient has "een hospitali#ed with pneumonia and is a"out to "e discharged. A nurse provides discharge instructions to a patient and his family. Which misunderstanding "y the family indicates the need for more detailed information? A. $he patient may resume normal home activities as tolerated "ut should avoid physical e ertion and get ade%uate rest. B. $he patient should resume a normal diet with emphasis on nutritious& healthy foods. C. $he patient may discontinue the prescri"ed course of oral anti"iotics once the symptoms have completely resolved. D. $he patient should continue use of the incentive spirometer to keep airways open and free of secretions.

'. A nurse is caring for an elderly (ietnamese patient in the terminal stages of lung cancer. )any family mem"ers are in the room around the clock performing unusual rituals and "ringing ethnic foods. Which of the following actions should the nurse take? A. *estrict visiting hours and ask the family to limit visitors to two at a time. B. +otify visitors with a sign on the door that the patient is limited to clear fluids only with no solid food allowed. C. ,f possi"le& keep the other "ed in the room unassigned to provide privacy and comfort to the family. D. Contact the physician to report the unusual rituals and activities.

-. $he charge nurse on the cardiac unit is planning assignments for the day. Which of the following is the most appropriate assignment for the float nurse that has "een reassigned from la"or and delivery?

A. A one-week postoperative coronary "ypass patient& who is "eing evaluated for placement of a pacemaker prior to discharge. B. A suspected myocardial infarction patient on telemetry& .ust admitted from the /mergency Department and scheduled for an angiogram. C. A patient with unsta"le angina "eing closely monitored for pain and medication titration. D. A post-operative valve replacement patient who was recently admitted to the unit "ecause all surgical "eds were filled.

0. A newly diagnosed 1-year-old child with type , dia"etes mellitus and his mother are receiving dia"etes education prior to discharge. $he physician has prescri"ed 2lucagon for emergency use. $he mother asks the purpose of this medication. Which of the following statements "y the nurse is correct? A. 2lucagon enhances the effect of insulin in case the "lood sugar remains high one hour after in.ection. B. 2lucagon treats hypoglycemia resulting from insulin overdose. C. 2lucagon treats lipoatrophy from insulin in.ections. D. 2lucagon prolongs the effect of insulin& allowing fewer in.ections.

3. A patient on the cardiac telemetry unit une pectedly goes into ventricular fi"rillation. $he advanced cardiac life support team prepares to defi"rillate. Which of the following choices indicates the correct placement of the conductive gel pads? A. $he left clavicle and right lower sternum. B. *ight of midline "elow the "ottom ri" and the left shoulder. C. $he upper and lower halves of the sternum. D. $he right side of the sternum .ust "elow the clavicle and left of the precordium.

4. $he nurse performs an initial a"dominal assessment on a patient newly admitted for a"dominal pain. $he nurse hears what she descri"es as 5clicks and gurgles in all four %uadrants5 as well as 5swishing or "u##ing sound heard in one or two %uadrants.5 Which of the following statements is correct? A. $he fre%uency and intensity of "owel sounds varies depending on the phase of

digestion. B. ,n the presence of intestinal o"struction& "owel sounds will "e louder and higher pitched. C. A swishing or "u##ing sound may represent the tur"ulent "lood flow of a "ruit and is not normal. D. All of the a"ove.

1. A patient arrives in the emergency department and reports splashing concentrated household cleaner in his eye. Which of the following nursing actions is a priority? A. ,rrigate the eye repeatedly with normal saline solution. B. 6lace fluorescein drops in the eye. C. 6atch the eye. D. $est visual acuity.

7. A nurse is caring for a patient who has had hip replacement. $he nurse should "e most concerned a"out which of the following findings? A. Complaints of pain during repositioning. B. 8cant "loody discharge on the surgical dressing. C. Complaints of pain following physical therapy. D. $emperature of 191.1 : ;'1.4 C<.

19. A child is admitted to the hospital with an uncontrolled sei#ure disorder. $he admitting physician writes orders for actions to "e taken in the event of a sei#ure. Which of the following actions would +=$ "e included? A. +otify the physician. B. *estrain the patient>s lim"s. C. 6osition the patient on his?her side with the head fle ed forward. D. Administer rectal dia#epam.

11. /mergency department triage is an important nursing function. A nurse working the evening shift is presented with four patients at the same time. Which of the following patients should "e assigned the highest priority? A. A patient with low-grade fever& headache& and myalgias for the past 4! hours. B. A patient who is una"le to "ear weight on the left foot& with swelling and "ruising following a running accident. C. A patient with a"dominal and chest pain following a large& spicy meal. D. A child with a one-inch "leeding laceration on the chin "ut otherwise well after falling while .umping on his "ed.

1!. A patient is admitted to the hospital with a calcium level of 3.9 mg?d@. Which of the following symptoms would you +=$ e pect to see in this patient? A. +um"ness in hands and feet. B. )uscle cramping. C. Aypoactive "owel sounds. D. 6ositive Chvostek>s sign.

1'. A nurse cares for a patient who has a nasogastric tu"e attached to low suction "ecause of a suspected "owel o"struction. Which of the following arterial "lood gas results might "e e pected in this patient? A. pA 4.0!& 6C=! 0- mm Ag. B. pA 4.-!& 6C=! -9 mm Ag. C. pA 4.!0& 6C=! !0 mm Ag. D. pA 4.'1& 6C=! '3 mm Ag.

1-. A patient is admitted to the hospital for routine elective surgery. ,ncluded in the list of current medications is Coumadin ;warfarin< at a high dose. Concerned a"out the possi"le effects of the drug& particularly in a patient scheduled for surgery& the nurse anticipates which of the following actions? A. Draw a "lood sample for prothrom"in ;6$< and international normali#ed ratio ;,+*< level.

B. Administer vitamin B. C. Draw a "lood sample for type and crossmatch and re%uest "lood from the "lood "ank. D. Cancel the surgery after the patient reports stopping the Coumadin one week previously.

10. $he follow la" results are received for a patient. Which of the following results are a"normal? +oteC )ore than one answer may "e correct. A. Aemoglo"in 19.- g?d@. B. $otal cholesterol '-9 mg?d@. C. $otal serum protein 4.9 g?d@. D. 2lycosylated hemoglo"in A1C 0.-D.

13. A nurse is performing routine assessment of an ,( site in a patient receiving "oth ,( fluids and medications through the line. Which of the following would indicate the need for discontinuation of the ,( line as the ne t nursing action? A. $he patient complains of pain on movement. B. $he area pro imal to the insertion site is reddened& warm& and painful. C. $he ,( solution is infusing too slowly& particularly when the lim" is elevated. D. A hematoma is visi"le in the area of the ,( insertion site.

14. A hospitali#ed patient has received transfusions of ! units of "lood over the past few hours. A nurse enters the room to find the patient sitting up in "ed& dyspneic and uncomforta"le. =n assessment& crackles are heard in the "ases of "oth lungs& pro"a"ly indicating that the patient is e periencing a complication of transfusion. Which of the following complications is most likely the cause of the patient>s symptoms? A. :e"rile non-hemolytic reaction. B. Allergic transfusion reaction. C. Acute hemolytic reaction. D. :luid overload.

11. A patient in la"or and delivery has .ust received an amniotomy. Which of the following is correct? +oteC )ore than one answer may "e correct. A. :re%uent checks for cervical dilation will "e needed after the procedure. B. Contractions may rapidly "ecome stronger and closer together after the procedure. C. $he :A* ;fetal heart rate< will "e followed closely after the procedure due to the possi"ility of cord compression. D. $he procedure is usually painless and is followed "y a gush of amniotic fluid.

17. A nurse is counseling the mother of a new"orn infant with hyper"iliru"inemia. Which of the following instructions "y the nurse is +=$ correct? A. Continue to "reastfeed fre%uently& at least every !-- hours. B. :ollow up with the infant>s physician within 4! hours of discharge for a recheck of the serum "iliru"in and e am. C. Watch for signs of dehydration& including decreased urinary output and changes in skin turgor. D. Beep the "a"y %uiet and swaddled& and place the "assinet in a dimly lit area.

!9. A nurse is giving discharge instructions to the parents of a healthy new"orn. Which of the following instructions should the nurse provide regarding car safety and the trip home from the hospital? A. $he infant should "e restrained in an infant car seat& properly secured in the "ack seat in a rear-facing position. B. $he infant should "e restrained in an infant car seat& properly secured in the front passenger seat. C. $he infant should "e restrained in an infant car seat facing forward or rearward in the "ack seat. D. :or the trip home from the hospital& the parent may sit in the "ack seat and hold the new"orn.

Answers Below

1. AnswerC C $he priority nursing action for a patient arriving at the /D in distress is always assessment of vital signs. $his indicates the e tent of physical compromise and provides a "aseline "y which to plan further assessment and treatment. A thorough medical history& including onset of symptoms& will "e necessary and it is likely that an electrocardiogram will "e performed as well& "ut these are not the first priority. 8imilarly& chest e am with auscultation may offer useful information after vital signs are assessed. !. AnswerC C ,t is always critical that patients "eing discharged from the hospital take prescri"ed medications as instructed. ,n the case of anti"iotics& a full course must "e completed even after symptoms have resolved to prevent incomplete eradication of the organism and recurrence of infection. $he patient should resume normal activities as tolerated& as well as a nutritious diet. Continued use of the incentive spirometer after discharge will speed recovery and improve lung function. '. AnswerC C When a family mem"er is dying& it is most helpful for nursing staff to provide a culturally sensitive environment to the degree possi"le within the hospital routine. ,n the (ietnamese culture& it is important that the dying "e surrounded "y loved ones and not left alone. $raditional rituals and foods are thought to ease the transition to the ne t life. When possi"le& allowing the family privacy for this traditional "ehavior is "est for them and the patient. Answers A& B& and D are incorrect "ecause they create unnecessary conflict with the patient and family. -. AnswerC A $he charge nurse planning assignments must consider the skills of the staff and the needs of the patients. $he la"or and delivery nurse who is not e perienced with the needs of cardiac patients should "e assigned to those with the least acute needs. $he patient who is one-week post-operative and nearing discharge is likely to re%uire routine care. A new patient admitted with suspected ), and scheduled for angiography would re%uire continuous assessment as well as coordination of care that is "est carried out "y e perienced staff. $he unsta"le patient re%uires staff that can immediately identify symptoms and respond appropriately. A post-operative patient also re%uires close monitoring and cardiac e perience. 0. AnswerC B 2lucagon is given to treat insulin overdose in an unresponsive patient. :ollowing 2lucagon administration& the patient should respond within 10-!9 minutes at which time oral car"ohydrates should "e given. 2lucagon reverses rather than enhances or prolongs the effects of insulin. @ipoatrophy refers to the effect of repeated insulin in.ections on su"cutaneous fat.

3. AnswerC D =ne gel pad should "e placed to the right of the sternum& .ust "elow the clavicle and the other .ust left of the precordium& as indicated "y the anatomic location of the heart. $o defi"rillate& the paddles are placed over the pads. =ptions A& B& and C are not consistent with the position of the heart and are therefore incorrect responses. 4. AnswerC D All of the statements are true. $he gurgles and clicks descri"ed in the %uestion represent normal "owel sounds& which vary with the phase of digestion. ,ntestinal o"struction causes the sounds to intensify as the normal flow is "locked "y the o"struction. $he swishing and "u##ing sound of tur"ulent "lood flow may "e heard in the a"domen in the presence of a"dominal aortic aneurism& for e ample& and should always "e considered a"normal. 1. AnswerC A /mergency treatment following a chemical splash to the eye includes immediate irrigation with normal saline. $he irrigation should "e continued for at least 19 minutes. :luorescein drops are used to check for scratches on the cornea due to their fluorescent properties and are not part of the initial care of a chemical splash& nor is patching the eye. :ollowing irrigation& visual acuity will "e assessed. 7. AnswerC D 6ost-surgical nursing assessment after hip replacement should "e principally concerned with the risk of neurovascular complications and the development of infection. A temperature of 191.1 : ;'1.4 C< postoperatively is higher than the low grade that is to "e e pected and should raise concern. 8ome pain during repositioning and following physical therapy is to "e e pected and can "e managed with analgesics. A small amount of "loody drainage on the surgical dressing is a result of normal healing. 19. AnswerC B During a witnessed sei#ure& nursing actions should focus on securing the patient>s safely and curtailing the sei#ure. *estraining the lim"s is not indicated "ecause strong muscle contractions could cause in.ury. A side-lying position with head fle ed forward allows for drainage of secretions and prevents the tongue from falling "ack& "locking the airway. *ectal dia#epam may "e a treatment ordered "y the physician& who should "e notified of the sei#ure. 11. AnswerC C /mergency triage involves %uick patient assessment to prioriti#e the need for further evaluation and care. 6atients with trauma& chest pain& respiratory distress& or acute neurological changes are always classified num"er one priority. $hough the patient with chest pain presented in the %uestion recently ate a spicy meal and may "e suffering from

heart"urn& he also may "e having an acute myocardial infarction and re%uire urgent attention. $he patient with fever& headache and muscle aches ;classic flu symptoms< should "e classified as non-urgent. $he patient with the foot in.ury may have sustained a sprain or fracture& and the lim" should "e -rayed as soon as is practical& "ut the damage is unlikely to worsen if there is a delay. $he child>s chin laceration may need to "e sutured "ut is also non-urgent. 1!. AnswerC C +ormal serum calcium is 1.0 - 19 mg?d@. $he patient is hypocalcemic. ,ncreased gastric motility& resulting in hyperactive ;not hypoactive< "owel sounds& a"dominal cramping and diarrhea is an indication of hypocalcemia. +um"ness in hands and feet and muscle cramps are also signs of hypocalcemia. 6ositive Chvostek>s sign refers to the sustained twitching of facial muscles following tapping in the area of the cheek"one and is a hallmark of hypocalcemia. 1'. AnswerC A A patient on nasogastric suction is at risk of meta"olic alkalosis as a result of loss of hydrochloric acid in gastric fluid. =f the answers given& only answer A ;pA 4.0!& 6C=! 0- mm Ag< represents alkalosis. Answer B is a normal "lood gas. Answer C represents respiratory acidosis. Answer D is "orderline normal with slightly low 6C=!. 1-. AnswerC A $he effect of Coumadin is to inhi"it clotting. $he ne t step is to check the 6$ and ,+* to determine the patient>s anticoagulation status and risk of "leeding. (itamin B is an antidote to Coumadin and may "e used in a patient who is at imminent risk of dangerous "leeding. 6reparation for transfusion& as descri"ed in option C& is only indicated in the case of significant "lood loss. ,f la" results indicate an anticoagulation level that would place the patient at risk of e cessive "leeding& the surgeon may choose to delay surgery and discontinue the medication. 10. AnswerC A and B +ormal hemoglo"in in adults is 1! - 13 g?d@. $otal cholesterol levels of !99 mg?d@ or "elow are considered normal. $otal serum protein of 4.9-g?d@ and glycosylated hemoglo"in A1c of 0.-D are "oth normal levels. 13. AnswerC B An ,( site that is red& warm& painful and swollen indicates that phle"itis has developed and the line should "e discontinued and restarted at another site. 6ain on movement should "e managed "y maneuvers such as splinting the lim" with an ,( "oard or gently shifting the position of the catheter "efore making a decision to remove the line. An ,( line that is running slowly may simply need flushing or repositioning. A hematoma at the site is likely a result of minor "leeding at the time of insertion and does not re%uire

discontinuation of the line. 14. AnswerC D :luid overload occurs when then the fluid volume infused over a short period is too great for the vascular system& causing fluid leak into the lungs. 8ymptoms include dyspnea& rapid respirations& and discomfort as in the patient descri"ed. :e"rile non-hemolytic reaction results in fever. 8ymptoms of allergic transfusion reaction would include flushing& itching& and a generali#ed rash. Acute hemolytic reaction may occur when a patient receives "lood that is incompati"le with his "lood type. ,t is the most serious adverse transfusion reaction and can cause shock and death. 11. AnswerC B& C& and D Eterine contractions typically "ecome stronger and occur more closely together following amniotomy. $he :A* is assessed immediately after the procedure and followed closely to detect changes that may indicate cord compression. $he procedure itself is painless and results in the %uick e pulsion of amniotic fluid. :ollowing amniotomy& cervical checks are minimi#ed "ecause of the risk of infection 17. AnswerC D An infant discharged home with hyper"iliru"inemia ;new"orn .aundice< should "e placed in a sunny rather than dimly lit area with skin e posed to help process the "iliru"in. :re%uent feedings will help to meta"oli#e the "iliru"in. A recheck of the serum "iliru"in and a physical e am within 4! hours will confirm that the level is falling and the infant is thriving and is well hydrated. 8igns of dehydration& including decreased urine output and skin changes& indicate inade%uate fluid intake and will worsen the hyper"iliru"inemia. !9. AnswerC A All infants under 1 year of age weighing less than !9 l"s. should "e placed in a rear-facing infant car seat secured properly in the "ack seat. ,nfant car seats should never "e placed in the front passenger seat. ,nfants should always "e placed in an approved car seat during travel& even on that first ride home from the hospital.